USAID Bureau for Global Health Fistula Strategy
2003-2008
Summary
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Strategic plan
The goal of the USAID Bureau for Global Health (GH) strategy is to reduce the prevalence and severity of obstetric fistula. The objective for GH is to advance and promote best practices and programs to prevent and repair obstetric fistula. To reach this objective, GH will improve the data base on the extent and severity of obstetric fistula, increase public and community awareness of the medical and social consequences of the problem, improve quality of care for prevention and repair, and support advocacy and improve policies that promote access to care that will prevent fistula.
Projected Results (5 Year Vision)
- Programs to prevent obstetric fistula will be strengthened
- Hospitals will be upgraded with surgical centers for training in repair of fistula
Background
Description and Magnitude of the Problem
Complications of pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. In addition to more than 500,000 maternal deaths annually, it is estimated that 15 million to 20 million women develop disabilities as a result of pregnancy and child birth. One of the most devastating is obstetric fistula that affects an estimated 2,000,000 women worldwide (WHO, 1989). This calculation could be a significant underestimate. The problem predominantly affects women in Sub-Saharan Africa and South Asia. Each year, an additional 50,000-100,000 estimated women are affected. UNFPA, EngenderHealth, and the Averting Maternal Death and Disability Program have and are now conducting assessments in a number of African countries to better define the nature and extent of the problem in Africa. Less is known about prevalence in South Asia but work has begun to assess the situation in Bangladesh.
Obstetric fistula is an abnormal opening between the vagina and the bladder or rectum (or both). Fistula, when connected with pregnancy, is a result of extreme pressure and tissue damage during prolonged or obstructed labor as the fetus attempts to pass through the mother’s birth canal. If a timely Caesarean section delivery is not available to end the ordeal, the baby is usually stillborn. The fistula that has formed permits the uncontrollable passage of urine and feces into the vagina.
Women who suffer from fistula have not only, in most cases, lost their babies, but also constantly leak urine and feces, producing a foul odor. In addition, some of these women also suffer neurological damage that can affect their ability to walk. Women with fistula usually feel shamed or disgraced, and are often deserted by their husbands and cut off from family, friends and daily activities, resulting in a life of isolation and destitution.
Determinants of Fistula Disability
The young and the poor are disproportionately affected. The women most at risk include the very young, women having their first birth, and women whose growth has been stunted due to malnutrition and childhood illness. Women who live in rural areas without access to services and women who use home delivery and traditional care are at highest risk.
Prevention
In the industrialized world, obstetric fistula is almost unknown. The reason is that most cases have been prevented. Access to skilled care including surveillance in labor is key. Whether or not a woman delivers at home, or in a health facility, there is time to detect prolonged labor and take action before the mother has prolonged, significant pressure on soft tissues to cause damage to her internal urinary, intestinal and reproductive systems.
One proven tool is the partogram that assists midwives and doctors to plot the progress of labor, as well as the condition of the mother and fetus, in labor. If any deviation from normal progress is noted on the partogram, the birth attendant is given a visual cue to be on the alert and to take action. This tool can be used in all settings where there is a skilled birth attendant and will allow timely initiation of transfer of the laboring mother, if necessary, and get her to a place where assisted delivery can be performed. In addition to skilled attendants and availability of emergency obstetric care, there needs to be a functioning referral system in place so that timely transfer to life saving care, in most cases a Caesarean section, can be achieved.
Fistula Repair
In the event that prolonged or obstructed labor is not detected in time to prevent the problem, surgical repair is possible, but often inaccessible. A large proportion may have a relatively “simple” tear that requires relatively straightforward surgical repair. Complicated cases of fistula involving extensive tissue damage and scarring need sophisticated surgical expertise. For all cases of repair, surgical expertise needs to be coupled with excellent postoperative care, including high quality nursing care, as well as psychosocial support.
Rehabilitation
Women who come for repair are often ashamed. Likewise, they are typically unemployed and have been rejected or isolated by their families. They lack support systems and persons to help them with this personal catastrophe. Experts working with fistula patients have found it essential to support skills training and psychosocial reintegration to move beyond only surgical repair to social rehabilitation. In some cases, these women are reintegrated with their communities. In other cases, especially where repairs are not completely effective, they need to develop new community systems to cope with the problem.
USAID’s Approach
Since 1989, USAID has actively and substantively supported programs to prevent disability from obstetric fistula. The programs has been designed to be integrated with other programs that address the major causes of maternal death and disability and that have the greatest potential for widespread public health impact. The programs have included:
- Increased access for women to emergency obstetrical
care -- USAID supports strengthened skilled care facilities, provider training and referral, and policy development to address financial barriers that prevent women from seeking treatment.
- Public awareness – USAID promotes public awareness campaigns that urge women to postpone marriage and childbearing until after the teenage years.
- Community training – USAID supports community awareness about the problem of prolonged labor and preparation for emergencies. Community members who are usually present or assist at birth are taught to recognize the danger signs of prolonged labor, which can lead to obstructed labor, fetal death, and fistula. Men, as the common decision makers for use of hospital services, are included in the community education.
- Increased attendance of skilled personnel at delivery -- Giving birth without a skilled attendant is a risk factor for fistula. USAID has substantively supported the improvement in quality of care by doctors, nurses and midwives in use of the partogram, recognition of prolonged labor, and referral to facilities that can provide surgery. USAID has become increasingly involved in workforce issues that affect the number and actual deployment of skilled attendants to locations where they are needed.
- Advocacy and awareness -- USAID raises awareness to advocate for increased attention to fistula and action. As an example, USAID has commissioned the Population Reference Bureau publication Hidden Suffering: Disabilities from Pregnancy and Childbirth in Less Developed Countries that highlights obstetric fistula.
Results Framework
In 2004, USAID will expand its efforts to address the problem of obstetric fistula. It will add to its current program, additional efforts to improve the evidence on the nature and extent of the problem and expand its programming to include fistula repair and linkage with rehabilitation support.
Enhanced Role for USAID Bureau for Global Health
-
Improve data base concerning the predisposing causes, prevalence and
severity of obstetric fistula disability
- Support data gathering, studies and analysis that improve evidence on the extent and severity of the problem
- Identify best practices to address prevention and treatment
- Improve public and community awareness about causes and medical and social consequences and
- Disseminate information about obstetric fistula in public forums, in written publications, and through the media to stimulate effective programs for births with a skilled attendant and to reduce stigma for those disabled by fistula
- Promote delayed marriage and childbearing through media messages and community and NGO activities.
- Improve services for prevention and treatment of obstetric fistula
- Promote access for all childbearing women to birth attendants with appropriate skills, including use of the partogram, within an enabling environment with appropriate supplies, equipment and drugs
- Improve quality of care for labor and delivery through standard setting, training, supervision and support, and quality improvement systems
- Support functioning referral systems, including communications and transport, to get women with prolonged /obstructed labor to emergency obstetrical care, including Caesarean section capability
- Improve quality of emergency care for labor augmentation and assisted/surgical delivery through standard setting for response to prolonged labor and monitoring and evaluation of treatment and related outcomes
- Support standard setting for best practices, training, quality assurance at centers of excellence for surgical repair
- Support linkage to social rehabilitation of affected women
Improve advocacy and policy support for improved access to safe delivery and care for obstetric complications
- Advance policy dialogue and formulation to change laws and norms to support family planning and delayed marriage and childbirth
- Improve access to emergency care through policy reform that addresses barriers to care including fee policies
Geographic Focus
Overall, special attention will be placed in Sub-Saharan Africa and South Asia where there magnitude and severity of the problem is greatest. Assessments on the extent of the problem will be focused in South Asia since considerably more has been done in Africa. Programming will be advanced where maternal mortality and disability is especially high and where the need is not being addressed by other partners.
Mechanisms and Funding
USAID will implement the obstetric fistula strategy through a variety of existing and new procurement mechanisms. These include a new maternal and neonatal health program under design, as well as two ongoing activities--The Futures Group/Policy Project and EngenderHealth/ACQUIRE.
Partnerships
The Bureau for Global Health will work with USAID missions in countries where there is a high prevalence of obstetric disability--taking advantage of targets of opportunity to work in surgical centers that USAID is supporting. In this way, USAID will be able to maximize its results to expand local capability in surgical repair.
UNFPA and WHO have taken an active role in addressing this problem and USAID will work closely with them. Additionally, USAID will work other partners, including skilled surgeons and local NGOs for surgical repair.
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